How Can Physical Therapy Help with Shoulder Pain?

Shoulder impingement, rotator cuff tear, biceps tendonitis, shoulder bursitis? A variety of diagnoses associated with the shoulder share several characteristics, the most significant being a sharp pain preventing dressing, reaching, driving, and / or sleeping. How can a good physical therapist help treat a rotator cuff that is partially torn?

If you’ve been keeping up on previous posts from Optimal Movement Physical Therapy you’ll know that Physical Therapy is not focusing on repairing damaged tissue, rather the focus is on identifying the reason the tissue became damaged in the first place. Once the faulty movement is identified, it can be corrected, and once it is corrected the pain can be alleviated. After all, many studies have shown that individuals can have a tear with no pain at all. Even further, the amount of pain that one has is not proportional to the size of the tear.

Well if the tear is not causing the pain, then what is causing the pain?

Take a look at the following video to better understand faulty mechanics.

Ideally, we want the humerus and the shoulder blade to move together in order to optimize the sub-acromial space. In this video, you can see the scapula does not move as the humerus moves which results in pinching of the structures within the subacromial space.

This poor movement results in impingement of the bursa, biceps, and part of the rotator cuff. Therefore this movement pattern can be the underlying cause of impingement, rotator cuff tear, bursitis, biceps tendonitis, just to name a few.

The sub-acromial space is a small tunnel where several structures pass through. With optimal biomechanics none of these structures become impinged. When the space is smaller because of poor posture, muscle imbalances, and / or faulty movement, the structures can become irritated and painful. Evidence of poor posture and muscle imbalance can be identified by a physical therapist examining your posture and movements. The area of focus for the therapist is the scapula, as the resting position and movement of the scapula is what determines the size of the space. When we are looking at your scapula we are determining whether the resting position is downwardly rotated, anteriorly tilted, and / or depressed as all of these positions will cause impingement.

An anterior tilt of the scapula is one where the inferior border is more prominent than the superior border.

Downward Rotation of the Scapula is one where the inferior angle is more medial than the superior angle of the scapula.

In the examples above, the scapula is starting in a poor position. This poor starting position results in a higher likelihood of impingement because the scapula will have difficulty getting full upward rotation. The scapula is in fact starting behind the starting line.

All hope is not lost. The scapula and it’s resting position, as well as how it moves can be retrained. Typically the muscles which are not “pulling their weight” include the mid and lower trapezius as well as the serrates anterior. At Optimal Movement Physical Therapy, we are looking for faulty scapula movements, testing for weakness at these muscles, and prescribing corrective exercises to eliminate the faulty mechanics.

The Other Side of ACL Rehabilitation

During my first affiliation, my clinical instructor and myself had the opportunity to assess an individual 5 days after he had undergone an Anterior Cruciate Ligament (ACL) reconstruction surgery.

5 days? Shouldn’t he still be recovering?  What exercises could he do? What should he not do? Should I put my hands on his knee? Why was he coming in to see us so soon?

Luckily, as a student physical therapist, I was not on my own, and I had a great clinical instructor. He picked up on my fear and understood the importance of not allowing that fear to be portrayed to the patient. It was a huge learning point for me, not only because I learned the proper ACL rehabilitation protocol, but I learned the importance of portraying confidence and giving reassurance to the patient.

Since that initial encounter with a patient who had undergone an ACL reconstruction surgery, I have rehabilitated hundreds of patients who had undergone a similar surgery. The reassurance and rehabilitation process has become second nature. There are stages of rehab, and goals that go along with each stage. The progression starts with ensuring quadricep activation and progresses to ensuring optimal neuromuscular control to minimize the risk of re-injury. From a physical therapists point of view, the rehabilitation process is pretty simple and straightforward. I don’t want to belittle the process, but unfortunately rehabbing an individual who has suffered an ACL rupture has become fairly common, and it can therefore be pretty easy as a practitioner to forget about the client. While this may be commonplace in a Physical Therapy clinic, the individuals going through this process are likely going through a challenge completely unlike anything they have ever done before.

Life has a funny way of reminding you why you are doing what you’re doing, and who you are doing it for. 

I was watching my beautiful 1 year old daughter, and my wife was behind me apparently doing a bunny hop. 2 milliseconds and a loud pop later and my wife was lying on the ground clutching her knee…

“I’m fine” she said minutes later as she attempted to stand and take a step, only to realize that her knee would not support her. My mind was racing,

Mechanism of injury – Check.

A loud pop – Check.

Instability and buckling – Check.

She needed an MRI. Any doctoral student, physical therapist, athletic trainer, and high school soccer player probably could tell you that those are the magic words for an MRI. Unfortunately, none of these people work for our country’s big insurance companies who requested documentation, an orthopedic surgeons prescription, and a precautionary x-ray (as if an x-ray would actually save them money?). On top of these requirements, the time it would take to get an appointment with a physician who could then refer us to an orthopedic surgeon in order to order an MRI was months away. This was simply not an option.

A favor from a local surgeon and money out of our pocket got the needed MRI, which of course revealed our suspicions. After asking around a bit, we found a great surgeon and we set the date.

And the babysitter.

And babysitters for the next month.

I was sitting in the waiting room the day of surgery thinking about what my wife was going through. Thinking about what she would be going through immediately after surgery. What happened to this being straight forward and simple?

It’s not just quadricep activation and knee flexion ROM when it’s you and your wife. It’s not just stages and goals when your daughter is confused by Mom’s inability to chase her. It’s not so easy and commonplace when it’s your wife who needs help with the brace and the timing of pain medication.

It’s over the last 2 weeks since my wife had her surgery that I get the reminder that we all need from time to time. Therapy is more than numbers and exercises. It has been a huge stepping stone for my wife going through one of the toughest challenges of her life. It has turned her from complete frustration to optimism in one hour’s time. The challenge is hers and ours to overcome, but we don’t have to do it alone. Therapy is about people and helping them with new challenges. Therapy is about chasing 1 year old daughters again.

The last 2 weeks of surgery and rehabilitation have definitely been challenging, but also a good refresher on the importance of the patient-therapist relationship. That patient is treading new territory, and the struggles associated with our insurance based healthcare system likely have not squashed any concerns the patients have. Each day brings a new step forward and my wife has started down her road to recovery. A great surgeon and rehabilitation team have definitely pushed her in the right direction, and provided some insight into what individuals go through during the rehab process.

More to come as rehab continues…

The 5 best local races for 2015

If you are the runner or cyclist in your family, chances are you will be unwrapping some new gear this holiday season and getting ready to shed some of the calories you’ve either intentionally or unintentionally put on during the holidays. Whether you are a competitive  veteran chomping at the bit to toe the line, or you are planing a training regimen for your first big race, one of the most exciting parts of doing a race is picking which one you’ll enjoy this year. The following is a list of some great local running races for you to gear up for, or to utilize as part of a training program for a bigger race.

1. Run through Redlands – March 8th 2015. 5K, 10K, 1/2M. This is a great run through some historic settings of Redlands. Prepare for some hill work as this run ascends from downtown through prospect park up to sunset before traversing back to the Redlands Bowl.

2. Highland Y Run – January 25 2015. 5K, 10K, and 1/2M. One of the best times to run in the Inland Empire is the winter while there are snow capped mountains and blooming citrus trees. All proceeds from this race go towards scholarships at the YMCA.

3. Citrus Heritage Run – January 10 2015. 5K and 1/2M. Ok, so maybe you should have already finished your training for this one. But if you are a seasoned runner, why not start the new year with an early run. This run is put on by a great local running group with proceeds benefiting local student athletes.

4. Redlands Chamber Night Light Run – December 27th 2014. 5K. The good news about this run, is not many people actually run it, rather they enjoy the show and move along a gradual pace. This run is in its 2nd year and the focus is have a good time while enjoying the lights around downtown Redlands. Look out for the Optimal Movement Physical Therapy Team this year!!!

5. Los Angeles Marathon – March 15, 2015. Marathon. If this race isn’t on your bucket list, it should be. It’s what most of the members of local run groups are training for and it is the best local marathon. The race course was changed several years ago to now incorporate a Dodger Stadium beginning and a Santa Monica finish (the one good thing Frank McCourt did for LA).

What local races are you looking forward to this year? Add your favorites in the comment section and let me know if I missed one. Remember to train safe and listen to your bodies rather than focus on a mileage goal. Also remember, you don’t run to be fit, you have to be fit to run. Let us know if you need our help with returning from an injury or optimizing your training plan to avoid an injury. Visit our website and get in touch with any running related questions you may have.

www.optimalmovementpt.com

How can Physical Therapy help with my Low Back Pain?

This post continues the discussion on how we as physical therapists can best treat our patients’ ailments. Check out the previous post regarding treatment and communication of a patient with knee pain here.

“Well, the reason for your low back pain is that you have degenerative disc disease.”

or,

“You have a slipped disc at L4/L5 which is compressing a nerve.”

or,

“the arthritis in your back is equivalent to a 90 year old.”

Pretty scary huh? How can physical therapy help with diagnoses like these? Can physical therapy remove the arthritis found on imaging?

No it cannot. But perhaps there are more important questions to ask. I would assume that the more meaningful question(s) may be; Can physical therapy eliminate the low back pain I experience when I am walking my kids to school. Can physical therapy allow me to lift items from the floor, and therefore allow me to perform my household duties? Can physical therapy eliminate the discomfort I experience while sitting for prolonged periods at work, and therefore allow me to be more productive? Can physical therapy eliminate the discomfort I have while I play recreational sports so that I can get back to playing basketball?

The answer to these questions is yes. But, look at the disconnect that many patients experience. Originally, they seek out a healthcare professional with a complaint during some type of meaningful activity. Rather than receiving an answer or a long term intervention, the original complaint gets warped into a diagnosis of “degenerative disc disease”, “arthritis”, or “stenosis”. Could it be that what’s causing the discomfort is not the diagnosis, but rather faulty movement?

Why do we rely on imaging to dictate the cause of our discomforts? Look at this research article performed on individuals without low back pain. This study utilized MRI images on individuals without low back pain. Only 36 percent of individuals without low back pain had “normal” findings. 52 percent had a disc bulge, and 27 percent had a disc protrusion. This, once again, begs the question, could it be that what’s causing the discomfort is not the diagnosis, but rather faulty movement?

This is actually great news for individuals suffering from low back pain. Nobody can treat  a diagnosis of stenosis or arthritis. But a movement expert can assess and implement a program to help individuals who have pain with specific activities. Treatment begins with identifying faulty movement, understanding the reasons for the poor movement, and specific corrective exercises to eliminate the poor mechanics.

For example, take a look at this diagram;

No diagnosis is causing this discomfort. Poor movement places a high amount of stress on the joint, the disc, the muscles, everything. Change the movement, change the pain. 

That being said, sometimes the desired activity requires more strength and flexibility than an individual has.

This individual likely does not have the core strength to lift appropriately given this quick movement screen. In order to lift appropriately, she may require a strengthening regimen. Every body is different and requires an individualized assessment and program prescription.  In order to get here, push your diagnosis to the side and begin identification of movements which may cause the discomfort.

Optimal Movement Physical Therapy is dedicated to helping individuals identify and treat their movement faults. Visit our website or e-mail us at alan@optimalmovementpt.com so that we may help answer any questions.

My Knee Pain is due to Arthritis, how can Physical Therapy Help?

“I have arthritis in my knee, can Physical Therapy get rid of the arthritis”?

No, it wont. Anybody that tells you differently is wrong.

In fact, you can replace the diagnosis with nearly any degenerative diagnosis for the knee.

Can Physical Therapy heal the torn meniscus?

No.

Can Physical Therapy heal the remove the cyst found under the patella.

No.

But, there’s a caveat. After confirming the patients correct belief that physical therapy cannot make the anatomical change which is the source of pain, the education typically goes something like this:

“Physical Therapy will not remove the arthritis found in your knee, but it’s possible that we can identify how your movement, flexibility, and/or strength issues may be placing excessive stress through your arthritic joint, therefore causing the pain. While we can’t remove the arthritis, if we relieve the stress we may remove the pain allowing you to perform your desired activity”.

Potential further education may be:

“In fact, the profession has done studies in which individuals without pain have similar radiographic findings as your x-rays. Potentially it is not the arthritis that causes the pain, but the stress placed on that arthritic joint during walking, ascending stairs, squatting, or any other movements is causing the pain”.

Let’s optimize movement to relieve the knee pain.

This is important education for Physical Therapists to give to their patients to assist in defining what the profession can do. Physical Therapists can help optimize movement to reduce the stress placed on the body. The switch from pain is due to the tissue source needs to be changed to the pain is due to the excessive stress placed on the tissue source.

How can changing movement change the amount of stress through the knee? Take a look at this research article which focuses on the amount of torque placed on the hip and knee during a common squat exercise.

Keep in mind that the squat is a very functional movement. What I mean by functional, is that this is a motion which is performed often by nearly all individuals. A simple motion of sitting in a chair, or lifting an item from the floor is a squat. Minimizing the amount of stress through the knee during a squat, therefore decreases the amount of stress through the knee during other functional tasks.

In this picture the amount of force placed through the knee is cut by 30% simply by cueing the individual to squat with his knees behind his toes. Imagine how much force could be eliminated when his strength and flexibility are even further optimized.

Check out www.OptimalMovementPT.com to learn how you can reduce the amount of stress through your painful knee, or any painful areas during your desired functional task.

TRX Corrective Exercises for Pitchers

You don’t run to get in shape, you get in shape so that you can run. Simply running every day will not improve your running ability. Cross training, improving muscle imbalances through corrective exercises, and strength training are all required in order to improve performance with running, and minimize the risk of overuse injuries.

You can take the same concept with any activity which requires repetitive motion, especially pitching. Simply throwing every day as hard as you can will only decrease performance and increase the likelihood of injury. There is a certain amount of core strength, rotator cuff stability, hip flexibility, and lower quarter stability that is required to optimize the movement of an overhead athlete. When an athlete has reached a certain level of strength and flexibility, I encourage using a TRX suspension strap to train these elements of pitching. My favorite TRX exercises for pitchers are listed below, but with a disclaimer: as healthcare professionals, we cannot simply prescribe exercises without a thorough examination of the athlete. These exercises should only be performed after an assessment and under the instruction of your healthcare specialist.

1) TRX Side Lunge

The stride phase of the pitch may be the most important phase of pitching. The stride length of a professional pitcher is approximately the length of the pitchers height, and the shoulder has to move towards end range of external rotation. Needless to say, in order to maintain proper mechanics the pitcher requires a certain amount of trunk control. Therefore, the TRX side lunge becomes a great exercise to work on adductor length of the stance leg (ensuring increased stride length) and trunk control during this motion.

2. TRX W Deltoid Fly

This exercise is named for the large deltoid muscle which assists with the abduction of the shoulder, but I like to use it to work the external rotators of the shoulder. This is also important for the stride phase of pitching, and requires a certain amount of instruction without the TRX before it can be done appropriately. After a pitcher learns appropriate joint centration of the glen0-humeral joint (to be discussed in a future blog) he can begin to train the rotator cuff to maintain the stability of the joint during pure external rotation. Again, all of this is being done while maintaining trunk control.

3. TRX T-Deltoid Fly

The cocking phase of the pitch requires scapula adduction and full external rotation of the gleno-humeral joint. At this phase of throwing, the middle trapezius operates at approximately 50% Maximal Voluntary Isometric Contraction (MVIC) and the Infraspinatus works at 74% MVIC. This exercise places works on these muscles to place the scapula and glen-humeral joint in the appropriate position for this phase of throwing.

4. TRX Lunge

 

Of particular note, at this time all exercises have focused on  phases of pitching before the ball is released (showing the emphasis I place on the early phases of pitching). The most important component of the pitch after the ball is released is the follow through. Flexing through the hip and trunk can attenuate the force developed in prior phases from the shoulder. The TRX lunge can work on strengthening the gluteals and hinging from the hip to assist with this phase of throwing.

This form of training requires appropriate flexibility, strength, and supervision, but it can greatly improve your pitching mechanics. If you live in the Redlands area, a great spot for TRX training is at The Energy Lab. Check them out for their TRX classes and all fitness goals.

For rehabilitation, movement screenings, and to work towards your fitness goals, check out OMPT and email me at alan@optimalmovementpt.com

 

http://www.optimalmovementpt.com

World Physical Therapy Day!!!

World Physical Therapy Day is September 8, 2014!!!

World Physical Therapy Day is a day to recognize the profession and all the benefits a Physical Therapist provides to the community. Are you currently participating in therapy? Have you had therapy in the past? How has therapy helped you? How could therapy help you?

For most individuals who have participated in therapy they are aware of the importance of the Physical Therapist as well as the role a therapist can provide in improving movement and function. For those of you who are not aware, the benefit therapy can provide is different for every individual. Every person you encounter has their own concerns and fears. My profession gives me the time to really understand and empathize with concerns and fears, which opens a window into making a real change on the individual level.

Whether it’s running that extra mile, picking up a grandson, getting up the stairs at night, or simply making it through the work day, Physical Therapists help individuals meet their specific goals. A Physical Therapist is a specialist on movement and can help optimize performance, return from an injury, and prevent future injuries from occurring. Imagine the health benefits of having a Physical Therapist who knows you. Think about it, most individuals have their own personal Physician and Dentist. Why not having your own Physical Therapist who can screen and educate on proper movements to maintain optimal health.

Optimal Movement Physical Therapy provides these benefits to many resident in the Redlands area. If you need someone on your team, we would be happy to listen to your concerns. Check out our website here. If you would like to learn more about World PT day, check out the World Confederation for Physical Therapy website.

In celebration of World PT Day we’re holding a contest! If your life has been significantly impacted by a Physical Therapist, let us know in the comments for a chance to win a $25 gift certificate to one of our favorite stores that encourages movement – REI! Follow us on Facebook, Instagram and Twitter for additional entries! Please leave individual comments letting us know where you’re following us! Giveaway ends Monday, September 15th at noon PST. Winner will be chosen by random draw and will be posted Monday evening!

Disclaimer: we are not affiliated with REI in any way. We just really like them and what they stand for!

http://www.OptimalMovementPT.com

A winner has been chosen for World PT Day contest. Thomas has been selected via the website random.org. Please email me at alan@optimalmovementpt.com.

Screening and Preventing ACL Injuries

This may be my favorite time of the year. Fall in Redlands is beautiful, and we finally move away from the heat of Summer into to crisp air of Fall. Cyclists and runners no longer have to get their workouts in early to beat the heat, and we get to look forward to playoff baseball. The aspect of Fall which I enjoy the most is the return of Football and Soccer. These sports showcase some incredible athletes performing at a high intensity level during nearly every play. The unfortunate side effect of this level of play is a multitude of anterior cruciate ligament (ACL) tears. So far in the NFL preseason alone (3 weeks of games) there have been 16 ACL tears: the most notable being Sam Bradford’s second tear. The average lost wage per NFL player who has suffered an ACL injury is 1.6 million dollars!

So what if some professional football players have had an injury? After all it should be expected for athletes in a heavy contact sport, especially in a league with the biggest and fastest athletes in the world, right? Well, are you aware that there are approximately 300,000 ACL injuries per year? Further, according to the Sports Surgery Clinic (SSC) in Dublin, 70% of ACL injuries occur during non contact injuries. Per the last stat from the SSC, female athletes are up to 8 times more likely to have an ACL injury than their male counterparts. This coupled with an average soccer player making approximately 726 cutting maneuvers in a game results in women’s soccer being the sport in which an ACL injury is most likely to occur.

70% of injuries occur without contact. This means that a tear occurs because of a biomechanical stress an athlete places on their ACL during cutting and/or running. Wouldn’t it be nice if we could screen for and prevent such a horrible injury from occurring?

The truth is, we can.

1) We know the population that typically has a non contact ACL injury. It will happen to young female athletes between the ages of 15 and 20. Every year, one in ten female collegiate athletes will have an ACL injury. Further, soccer and football athletes are most likely to have the injury given the demands they place on their knee.

2) We know the mechanism of injury. The injury occurs during periods of cutting or changing directions. Typically the knee is slightly bent, and there is a large valgus force placed on the knee.

Since we know these two facts, we can effectively screen for these injuries. We simply have to analyze the movements of the at risk population. With video analysis, we can determine if an athlete places a high amount of valgus stress at the knee during cutting and jumping drills. With a simple quick screen, athletes who are at a risk for an ACL injury can be identified.

So then what? A study performed by Mandelbaum et al in 2005 showed that athletes invoked in a Prevent injury and Enhance Performance program (PEP) were approximately 80% less likely to have an ACL injury. This program is made up of exercises focusing on flexibility and proximal hip stability.

So, a short screen of athletes, followed by prescription of individualized strengthening exercises can prevent 80% of the 300,000 ACL injuries that occur each year.

One more blurb on ACL injuries. A shift in the rehabilitation after an injury has been occurring of late. No longer are physical therapists following a set protocol. Instead, rehab is being progressed based on biomechanical testing. Biomechanical testing is now being done to clear athletes to return to sport in order to prevent the 12% chance of a re-injury. Given that we are screening athletes who have had an ACL injury before they return to sport, doesn’t it make sense that we begin using biomechanical testing to avoid injuries in the first place?

At Optimal Movement Physical Therapy, we focus on screening and preventing injuries. The video analysis and screening for ACL injuries, as well as ACL rehabilitation and return to sport are all services provided. Call us today to schedule your free consultation at 909-335-7402!

http://www.optimalmovementpt.com